tbuckley/cabot-search huggingface dataset:
P44 Can dermatologists help save the planet?
Authors: Anjeli Taheem, Shafiah Muna Abdul Gafoor, Emma Woodcock, Toby Nelson
Journal: British Journal of Dermatology (2023)

Abstract The National Health Service (NHS) is England’s largest contributor to public greenhouse gas emissions, accounting for 6.3% of the country’s carbon footprint (Tennison I, Roschnik S, Ashby B et al. Health care’s response to climate change: a carbon footprint assessment of the NHS in England. Lancet Planet Health 2021; 5:e84–92). Promoting sustainable practices within dermatology is often overlooked and remains an understudied area of research. Dermatologists should consider environmental sustainability when choosing their day-to-day personal protective equipment (PPE). An over-reliance on sterile PPE for minor surgical practices costs millions of pounds annually, ultimately occupying landfills and causing detrimental effects to our ecosystem. Are these sterile practices really improving clinical outcomes and reducing the prevalence of surgical site infections (SSIs)? Over the last decade, there has been an emphasis on comparing the use of sterile vs. nonsterile gloves and associated SSI rates in dermatology and Mohs micrographic surgery (MMS). MMS is often conducted with two sterile gloves and two surgical gowns. According to the sustainability guidance published by the British Society for Dermatological Surgery, surgical aprons and nonsterile gloves are preferred to surgical gowns and sterile gloves in procedures such as diagnostic biopsies, simple excision, tumour extirpation stages in MMS and outpatient reconstructive surgeries (https://bsds.org.uk/wp-content/uploads/2022/09/2022-BSDS_Sustainability_Guidance.pdf). Based on this guidance and to reduce our carbon footprint, we decided to use two plastic aprons, one pair of nonsterile and one pair of sterile gloves from August 2020 to September 2022. Of 410 MMS procedures conducted, only 1.7% resulted in a minor postoperative complication related to infection. Our data suggest no significant difference in postoperative wound infections with the use of nonsterile PPE vs. sterile PPE. Moreover, the use of nonsterile PPE has saved our department £1471.90, allowing funding to be distributed to other areas. In line with the NHS multiyear plan to become the world’s first carbon net zero national health system by 2040, we should invest in processes that facilitate sustainable alternatives to construct a fully operational eco-friendly healthcare system. By using less PPE in reconstructive surgeries, we reduce plastic waste. Despite not being able to remove PPE completely, we can make dermatology more sustainable, to help save the planet we live on.
BT17 Patient Assessment Wrap-up Session: the utility of consensus decision-making in teledermatology
Authors: Sanaa Butt, Sayeda Nahar, Paul Gazzani, Farida Shah, Agustin Martin-Clavijo, Emily Akufo-Tetteh, Shireen Velangi
Journal: British Journal of Dermatology (2023)

Abstract In our unit, skin cancer referrals are triaged via teledermatology following high-quality image capture of lesions, including dermoscopic views. Patients are discharged, invited for a face-to-face assessment or listed directly for surgery. Remote and asynchronous consultations are at odds with the traditional clinical training all our consultants underwent, and therefore introduce new uncertainty into our work. As a way to maximize remote discharges, and improve the consistency of and the confidence in our own teledermatology diagnoses, we developed Patient Assessment Wrap-up Session (PAWS). This is an email-based discussion group allowing consensus decision-making on cases with lesions that demonstrate some ambiguity and that individually we would usually bring to a face-to-face appointment. Between March and April 2022, a total of 566 teledermatology cases were allocated to five consultants within the department. In total, 476 (84.1%) were dealt with independently by the allocated consultant. The remaining 90 cases (15.9%) were discussed via PAWS, with 48 (53%) being discharged as a result. On average, four clinicians responded to the PAWS request, and the average time to reach a consensus was 14 h. Of those discharged, two were re-referred within 6 months, one for different lesions and one for the same noncancerous lesion; however, both were discharged again. The additional discharges led to 16 h of clinic time saved, but the PAWS time cost between 12 and 18 h. Although PAWS is currently probably consultant-time neutral, the timing is more flexible than a face-to-face clinic. Additional advantages have also become apparent while using the process. It aids continued professional development and peer assessment while simultaneously providing a service. The patients discharged after PAWS are also saved from a fossil fuel burning visit to the hospital and having to take time off work, and so on. The PAWS also allows for junior colleagues to leverage support from more experienced clinicians when balancing risk and dealing with difficult decision-making. We would like to share our PAWS process as it may also benefit other services using teledermatology.
P26 Risk factors for complications in cutaneous squamous cell carcinoma and proposal of a simplified follow-up strategy, making use of available healthcare resources
Authors: Daniel Micallef, Alicia Dimech, David Pisani, Liberato Camilleri, Lawrence Scerri
Journal: British Journal of Dermatology (2023)

Abstract Cutaneous squamous cell carcinoma (cSCC) is a common malignancy, generally cured by surgical excision. A minority of such tumours recur, metastasize or even cause death. The 2021 British Association of Dermatologists (BAD) guidelines outline high-risk features that are used to guide the follow-up of patients after a primary cSCC. The aims of this study were to identify histological features of cSCC that are significantly associated with the development of complications, and to compare the sensitivity, specificity and number of appointments required to follow-up patients using different follow-up criteria. In total, 556 cases of primary invasive cSCCs excised between January 2014 and March 2018 were included and followed-up for a minimum of 4 years. Five per cent (n = 26) of tumours were associated with at least one cSCC-related complication, namely, local recurrence 3.8% (n = 21), nodal metastasis 1.6% (n = 9), distant metastasis 0.4% (n = 2) and disease-specific death 0.7% (n = 4). The initial diagnosed complication was local recurrence in 20 of 26 cases. Only two patients had the first complication beyond 2 years of the original cSCC. Factors that were statistically significantly associated with the development of a complication (P &amp;lt; 0.001) are larger diameter, larger depth of invasion, tumour invasion beyond the dermis, perineural invasion (irrespective of size), lymphovascular invasion, gross bone erosion and deep margin &amp;lt; 1 mm. Differentiation and peripheral margin were not significantly associated with complications. Therefore, it may be proposed that patients with tumours with at least one of the following risk factors be followed-up: diameter &amp;gt; 40 mm; depth of invasion &amp;gt; 6 mm; invasion beyond the dermis; presence of perineural or lymphovascular invasion or deep margin &amp;lt; 1 mm. In adopting these criteria, 739 appointments in 156 patients would be required over 2 years (4 monthly during the first year and 6 monthly during the second year). Twenty of the patients who developed a complication would be followed-up (sensitivity 76.9%, specificity 69.4%). Using the BAD guidelines, up to four more patients with complications would have been followed-up (sensitivity 92.3%, specificity 44.7%), but this would have required a total of 1556 follow-up visits in 242 patients. Given the limited resources, patient burden and the fact that local recurrence is most often the first complication, it may be reasonable to offer routine follow-up only to patients who have at least one of the proposed criteria. Coupled with patient education, this strategy could greatly reduce the number of follow-up visits required. Such a strategy may allow resources to be utilized to reduce waiting times, particularly for 2-week wait referrals, decreasing the delay in new skin cancer diagnoses.
PA22 Topical tacrolimus management of chronic recurrent skin reaction to mauve stinger jellyfish envenomation
Authors: Cavan West, Virginia Alessandrini, Julia K Gass
Journal: British Journal of Dermatology (2023)

Abstract Chronic skin eruptions may follow the acute reaction to envenomation by some jellyfish, the incidence and management of which are not well described. We describe management with topical tacrolimus of a chronic eruption following envenomation by Pelagia noctiluca (‘mauve stinger’), one of the most common stinging jellyfish in the Mediterranean Sea. An 8-year-old girl was stung on the arm by a P. noctiluca in Menorca, Spain. First-aid measures with vinegar and topical antihistamine were administered, and the discomfort settled within 24 h. Five days later, the sting site became increasingly painful and itchy, with superficial ulceration and arm swelling. A second sting site on the lower leg reacted in a similar manner. She was systemically well. She was treated with oral co-amoxiclav, fusidic acid and betamethasone valerate 0.1% cream, and nonadhesive dressings. She initially responded well, but was required to continue the use of potent topical steroid after 3 weeks, as the symptoms recurred within 48 h of halted application. The use of topical tacrolimus cream 0.03% achieved symptom control when used in a slowly weaning regime over 3 months, with a brief flare of skin symptoms around the time of contracting COVID-19. She has now been asymptomatic for 12 months, and the sting site is a maturing scar. Envenomation reactions to jellyfish of the phylum Cnidaria (including P. noctiluca) are the result of varying pathophysiological mechanisms. The tentacles and bell of P. noctiluca carry toxin-releasing epithelial organelles called nematocysts. When triggered, the stinging apparatus fires, injecting thousands of mineralized spine-covered tubules and toxins such as porins [Yanagihara AA, Wilcox C, Smith J, Surrett GW. Cubozoan envenomations: clinical features, pathophysiology and management. In: The Cnidaria, Past, Present and Future (Goffredo S, Dubinsky Z, eds). Cham: Springer, 2016; 637–52]. Acute tissue damage and inflammation are caused by physical trauma and venom effects. Vinegar used at the time of a sting may permanently prevent discharge from unfired and noninjected nematocysts. Hot-water immersion for 30 min inactivates venom, and topical steroids reduce inflammation. The delayed and prolonged skin response (presenting after the primary reaction to envenomation), as in our case, is likely to be an immunological response to the retained, embedded nematocyst structures and may include granulomatous reactions, and eventually scarring. Optimal acute first-aid measures (as above) are thought to reduce incidence of late skin sequelae. This report highlights the successful use of topical tacrolimus immunomodulation for an established delayed reaction.
BG09 <i>RASA1</i> exon deletion in a neonate with vascular malformations
Authors: Nina Mann, Lea Solman, Claire Searle, Jothsana Srinivasan, Jane C Ravenscroft
Journal: British Journal of Dermatology (2023)

Abstract A full-term infant was noted to have a large, macular, pale-pink vascular birthmark across the left side of the chest, extending to the upper arm. Three smaller pale-pink irregular birthmarks on the elbow, thigh and flank were noted, as was an enlarged left upper arm. He had an oxygen dependency shortly after birth for which he required admission to the neonatal unit. A detailed history revealed that his father, paternal grandmother and aunt had similar birthmarks. His paternal aunt had an episode of bleeding from a spinal arteriovenous malformation (AVM) in her teens, which had been investigated with genetic testing by Sanger sequencing, but this did not identify a variant in RASA1. Following involvement from the dermatology, neonatology, genetics and radiology teams, investigations were organized. Findings included a high-flow vascular malformation with arteriovenous shunting on magnetic resonance imaging (MRI) of the left arm, normal MRI head and spine, and normal cardiac anatomy. Genetic testing by next-generation sequencing detected a heterozygous exon 21–23 deletion in RASA1. A diagnosis of capillary malformation–AVM syndrome (CM–AVM) was confirmed. Results of genetic testing of the father are awaited. Referral to a tertiary centre for consideration of management of AVM is underway. CM–AVM is a rare autosomal dominant condition. Pathogenic variants in RASA1 result in a lack of functional p120-RasGAP protein, which leads to abnormalities in angiogenesis, although this pathway is not well understood (Wooderchak-Donahue W, Johnson P, McDonald J et al. Expanding the clinical and molecular findings in RASA1 capillary malformation-arteriovenous malformation. Eur J Hum Genet 2018; 26:1521–36). Cutaneous vascular malformations, classically pink–red with a pale halo, are the most consistent cutaneous manifestation, but they may be subtle and can mimic other vascular birthmarks such as segmental infantile haemangioma, salmon patches or port wine stain. In our patient, pale halos were not apparent until 4 months of age. Identification is important as life-threatening complications from cutaneous vascular arteriovenous fistulas can occur (Wooderchak-Donahue et al.). This case highlights the importance of clarifying a family history, classifying vascular birthmarks and working with the multidisciplinary team. Genetic testing should be considered, even with previous negative analysis, as test sensitivity has improved and will now include analysis of EPHB4, which has also been associated with CM–AVM.
DP07 The effect of the COVID-19 pandemic on the Breslow thickness of melanoma at presentation
Authors: Eva Lau, Joanne Bowers, Katherine Humphris, Louise Binns, Benjamin Walker, Alison Layton
Journal: British Journal of Dermatology (2023)

Abstract The COVID-19 pandemic has caused significant disruption in dermatology healthcare due to patient concern over attending appointments, their conscious effort not to overwhelm services and, in many areas, reduced access to clinical care in the community. This was a single-centre service evaluation of the thickness and staging of melanomas presenting to a secondary care dermatology unit, before, during and after the COVID-19 pandemic. The primary aim was to assess whether there was an increase in tumour thickness and melanoma stage in newly referred patients diagnosed with melanoma postpandemic vs. those presenting prepandemic. Melanoma staging and tumour thickness data were extracted from the local histopathology database for all patients with a melanoma diagnosed at a new patient clinic appointment during the years 2018–2019, 2020–2021 and 2021–2022. Data were subsequently tabulated and analysed. Seventy-five malignant melanomas were identified from 2018 to 2019, with a mean (SD) tumour thickness of 1.47 (2.16) mm. From 2020 to 2021, 93 melanomas were identified with a mean (SD) tumour thickness of 2.17 (3.13) mm. Between 2021 and 2022, 121 melanomas were identified with a mean (SD) tumour thickness of 1.58 (2.70) mm. The mean increase in melanoma thickness between 2018–2019 and 2020–2021 was 0.70 mm (P = 0.10). There was an increase in thicker and higher-stage melanomas diagnosed in 2020–2021, 27 of stage 3A–4C, vs. 17 in 2018–2019 (P = 0.35). Comparing prepandemic lesions with postpandemic ones, the overall number of lesion diagnoses increased from 75 to 121; however, there has not been a statistically significant change in mean thickness (P = 0.77) or the number of higher-grade lesions seen (P = 0.58). In conclusion, there was an increase in the average tumour thickness and melanoma staging immediately after the height of the COVID-19 pandemic. This resonates with published data examining the impact of COVID-19 on melanoma diagnosis from the USA (Weston GK, Jeong HS, Mu EW et al. Impact of COVID-19 on melanoma diagnosis. Melanoma Res 2021; 31:280–1). Further data will be extracted to assess if patient demographics and history for the duration of the presenting lesion correlated with delay in presentation and thicker lesions. It would be interesting to compare data from other dermatology units to see whether there is a similar trend and to collate the patients’ outcomes to evaluate whether patients with delayed presentation have worse prognoses.
BG03 The first case of Haim–Munk syndrome in the UK
Authors: Rebecca McCarthy, Dushyanth Gnanappiragasam, Matthew Scorer, Marisa Taylor, Edel O’Toole
Journal: British Journal of Dermatology (2023)

Abstract Haim–Munk syndrome (HMS) and Papillon–Lefevre syndrome (PLS) are rare, autosomal recessive palmoplantar keratodermas (PPKs) characterized by PPK and periodontal inflammation. They are phenotypic variants of clinically related syndromes caused by homozygous or compound heterozygous mutations in cathepsin C (CTSC) on chromosome 11q14. Specific features of HMS include pes planus, radiographic deformity of the fingers, arachnodactyly, acro-osteolysis and onychogryphosis. In contrast, PLS can be associated with neurological disorders, calcification of the dura mater, hyperhidrosis and susceptibility to infection. Fewer than 100 cases of HMS have been reported, the majority of which have come from the Cochin region of India. We describe the case of a phenotypic presentation of HMS, with a novel mutation in CTSC. To our knowledge, this is the first case of HMS in the UK. The patient was a 14-year-old male, born in Gujarat, India, to consanguineous, healthy parents. He migrated to the UK in his early teens and was referred for a specialist opinion of symptoms of ichthyosis and PPK, which had been present from the age of 8 years. He was treated with acitretin in India, before moving to the UK. Physical examination revealed transgradient PPK, generalized mild ichthyosis, periodontal inflammation, dystrophic fingernails and toenails, and marked deformities of the fingers, including contractures, subluxation and swan-neck deformities, with a degree of arthritis. Bilateral hand radiographs showed slender, long bones, with extension/flexion deformities at several sites but no erosions. Laboratory investigations revealed low iron, folate and vitamin D levels. Based on the clinical and radiographic findings, a diagnosis of HMS was made. The patient was continued on acitretin, soap substitutes, regular emollients, iron, folate and vitamin D supplementation and referred to occupational therapy for hand splinting. Next-generation sequencing identified an autosomal recessive, homozygous c.901G&amp;gt;A (p.Gly301Ser) variant of CTSC. A total of 75 mutations, in a diverse range of ethnic groups, have been reported in CTSC; the majority (97%) is reported in PLS. The variant seen in our patient has previously been reported in PLS; however, to our knowledge, it has not been associated with the HMS phenotype. This case details the first homozygous c.901G&amp;gt;A CTSC variant in a patient with HMS. To date, the genotype–phenotype correlations in PLS and HMS have not been established, largely due to the rarity of these conditions. This report adds to existing literature and expands on the understanding of clinical findings associated with CTSC mutations.
BI11 Cutaneous presentation of Kaposi sarcoma following allogeneic haematopoietic stem cell transplantation for myeloma
Authors: Conn McGrath, Bjorn Thomas, Mhairi Duncan, Tanya Basu, Reuben Benjamin, Fiona Child
Journal: British Journal of Dermatology (2023)

Abstract Iatrogenic Kaposi sarcoma (KS) is a relatively frequent occurrence following solid-organ transplants (0–5%), in part due to prolonged immunosuppression. However, its occurrence after haematopoietic stem cell transplantation (HSCT) is rare, with only 15 cases described in the literature. We report a case of KS presenting in the skin of a patient who had received a matched unrelated donor allogeneic HSCT for IgG kappa myeloma. A 55-year-old HIV-negative white man with myeloma underwent an allogeneic HSCT from a matched, unrelated donor following conditioning chemotherapy with fludarabine–melphalan and antithymocyte globulin. Post-transplant, he was maintained on ciclosporin as graft-versus-host disease (GVHD) prophylaxis. On day 14 post-transplant, he developed a widespread eczematous eruption that rapidly evolved into an erythroderma; a skin biopsy was consistent with acute GVHD. He was managed with superpotent topical steroids and a 5-day course of oral prednisolone. He began extracorporeal photopheresis (ECP) on day 33 post-transplant, having failed to respond adequately to systemic steroids. He also completed four cycles of rituximab. Ciclosporin was stopped by day 130 post-transplant. He had completed 14 cycles of ECP by day 139 post-transplant, with resolution of cutaneous GVHD; however, he had developed a rapidly growing solitary dusky-red nodule on his right neck that was excised due to diagnostic uncertainty. Histology revealed a dermal haemorrhagic exophytic vascular tumour composed of lobules and sheets of epithelioid cells with an eosinophilic cytoplasm and pleomorphic nuclei. Immunoperoxidase staining was negative for S100, MNF-116 and AE1/AE3. The same cells were strongly and diffusely positive for the vascular markers CD31, CD34 and ERG. The lesional cells were positive for human herpesvirus (HHV)-8 confirming a diagnosis of Kaposi sarcoma. He subsequently developed a second lesion on his left forearm, despite being off all immunosuppression. A repeat bone biopsy confirmed that he remains in morphological remission from his myeloma. Positron emission tomography–computed tomography has not identified extracutaneous disease. KS following HSCT is rare, but it can be fatal. Skin lesions are the dominant clinical presentation. HHV-8 has an important role in the pathogenesis, and transplant-related KS may occur secondary to reactivation of the virus as a result of significant immunosuppression following HSCT. However, it could also occur as primary infection or be transmitted with donor cells. The outcome of KS after HSCT is variable. A watch and wait strategy can be applied if immune recovery is expected. In our patient, it developed 5 months after HSCT; shortly after immunosuppression had been tapered, he remains well and will be closely monitored for further suspicious lesions.